COVID-19
PCR test application form

Please fill in the required items on the PCR test application form

Note：Please take a photo【health insurance card】or【medical beneficiary certificate】and send

※(Required input)

※Name (in Block)
※In Japanese (Furigana)
Examination ticket number If you do not have a medical examination ticket number, leave it blank
※Sex (M/F)
Please select Male Female
※Mail Address
※Date of Birth
year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 month - 1 2 3 4 5 6 7 8 9 10 11 12 day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
※Age
Please select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
※Phone Number
※Postal code
※address
Car features If you come by car, please let us know the characteristics of your car.
※Purpose of PCR test
I want to inspect because there are positive people and close contacts around me. The health center told me to inspect. I was told to inspect at the company. Somehow I'm worried, so I'd like to check it just in case. I have symptoms, so please have a medical examination. others
※Do you have a fever?
yes no
※Do you have any other symptoms?
yes no
※If negative, do I need a certificate?(￥3,300-) We will give you the result table of the inspection company free of charge, but it will take 2 medical treatment days.
yes no
※Please take a picture of your health insurance card and attach an image. If you have a medical beneficiary certificate, please take a picture of your medical beneficiary certificate and attach an image.